The Decibel - Rise in late-stage prostate cancer raises concerns over testing

Episode Date: December 11, 2025

Late-stage prostate cancer diagnoses are on the rise in Canada. According to a recent study, between 2010 and 2021, rates of prostate cancer discovered at Stage 4 increased by about 50 per cent in men aged 50 to 74. In men over the age of 75, rates were up over 65 per cent.There is a simple blood test that can screen for early signs of prostate cancer, called a prostate specific antigen, or PSA test; however, in 2014, Canada recommended against using the PSA for widespread screening. Today, Globe health reporter Kelly Grant explains what this study found and why these guidelines are so highly contested in Canada.Questions? Comments? Ideas? Email us at [e-mail] Hosted by Simplecast, an AdsWizz company. See pcm.adswizz.com for information about our collection and use of personal data for advertising.

Prasate cancer is the third most commonly diagnosed cancer in Canada. This year, more than 5,000 people are expected to die from it. And according to a new study by researchers at the University of British Columbia, the University of Ottawa, and Statistics Canada, the rate of late-stage diagnoses, when the cancer has spread and is considered incurable, is going up. There's a simple blood test that can screen for prostate cancer before it's symptomatic, called the prostate-specific antigen or PSA test. In 2014, Canada recommended against doing widespread screening for prostate cancer using the PSA test.

And some people are wondering, if not doing PSA screening, means we're missing the chance to catch cases earlier. Today, Kelly Grant, a health reporter for the globe, is here to talk about what this study found and why cancer screening guidelines in Canada are so hotly debated. I'm Cheryl Sutherland and this is the decibel from the Globe and Mail. Hi, Kelly. Thanks for coming on the show. Thanks for having me, Cheryl. Okay, Kelly, so this new study looks into prostate cancer in Canada and it came out at the end of November. What did the study find? The biggest takeaway finding here is the way that diagnoses at stage have changed. So what the study found, among many other things about prostate cancer,

but this was the thing that really jumped out to me, was that there had been a notable increase in the rates of cancer discovered at stage four, which is when prostate cancer is incurable. It's metastatic. It's spread. And even though there are some treatments that can prolong life, it is incurable if found at that stage. So the increase in rates between 2010 and 2021, for men in the age group of 50 to 74 was about 50%. And then there was a higher increase of about 65% in men over the age of 75 in terms of finding those stage 4 diagnoses. I mean, those percentages sound quite high. So you have to keep in mind that those are relative increases, and that is over a period of more than a decade.

But it is notable that the medical system is finding more cases later in the course of prostate cancer disease. now than in the past. Let's talk about this later stage diagnoses that we're seeing. Like, what is the difference between outcomes when it comes to stage four prostate cancer versus stage one? Yeah, they're very significant. So actually at stage one, two, and three, prostate cancer is almost always curable. At stage four, which, as I said, means it's metastatic and it's spread outside the prostate. At that point, it is incurable. Now, there has been some improvement in treatments of late stage disease so that people are surviving longer with it. But it is, sadly going to get you in the end if you find it that late.

The study looked at rates of prostate cancer from 1984 through to 2021, so almost a 40-year period. When it comes to screening practices for prostate cancer, what changed over that time? So there were a lot of changes in how screening for prostate cancer happened during that period. There's something called the prostate-specific antigen test, which people may have heard of called the PSA test. Now, this test was long in use as a way to monitor men who had prostate cancer. If you ever diagnosed with this as they're monitoring your disease, you'll get your PSA levels checked regularly. In the 80s, there was a move towards recognizing that the PSA test could be used as a screener. So a screener is where you're testing men who don't

have any symptoms of the disease as a way, hopefully, to try to catch it early. So in the late 80s and early 90s, it started to become quite broadly used as a screener. Then over time, as it became clear that there was a really large increase in incidence, right, which means how often you're diagnosing prostate cancer, there started to be some concerns about overdiagnosis and over-treatment. And when that happened, task forces that take a look at these big questions, I've had a screen for cancer in both the United States and in Canada, eventually came to the conclusion that they felt it was a bad idea to use the PSA as a screener, basically because these task forces felt that the harms and the risks outweigh the benefits.

Okay. And when someone gets a PSA test, like what's involved? It's a simple blood test. Okay. So let's get into kind of the recommendations now, because the U.S. recommended against PSA tests in 2012, and Canada followed suit in 2014. Why is that?

And we talked about the harm a little bit, But on the surface, it would seem like testing for prostate cancer shouldn't be controversial. So in the case of both of those U.S. and Canadian recommendations, the thinking behind those was that, like I said earlier, the harms and risks outweighed the benefits of catching early. And the main reason for that is that if you overdiagnose and then overtreat prostate cancer that may have been very slow growing, may have not. never caused problems if it hadn't been caught through PSA screening, that you open up men to the risk through biopsy and then later through surgery of having some really bad outcomes related to that. If you have a biopsy of the prostate or surgery to remove a prostate, men do run the risk of suffering erectile dysfunction and incontinence. And so the voices who said,

hey, we think this is too risky, felt that those kinds of outcomes, that that harm outweighed the benefit that might come along with finding a prostate cancer earlier in the course of the illness. Okay. And my understanding also is that prostate cancer is a slow-growing cancer, right? So the sense is that if you overdiagnose, it's the idea that perhaps you're catching some things too early and maybe treating it too early and causing these harms that you're talking about.

That is definitely the position of people who think the PSA test is. is too much of a risk. Now, on the other side of the argument, I often hear from urologists and oncologists who treat prostate cancer that they too understand the risks of overdiagnosis and overtreatment. And as a result, that the specialty has become very focused on doing something called active surveillance. So that when somebody gets a high PSA reading, rather than jumping in with a biopsy or treatment, they will do something that's more like watchful waiting. And they will, you know, instruct the men to have their PSA levels tested, you know, every year or whatever the appropriate interval is. And then they'll just kind of keep an eye on whether the cancer is growing.

And if it does, then they will make a decision about whether to do a bit more active treatment. Another thing that has changed that I've had lots of people point out to me here is that rather than going immediately to a biopsy, there has been a move towards using MRIs to take a look at any concerning findings on a PSA test. and the risks of an MRI are generally lower than the risks of a biopsy. Okay, interesting. And so the idea here is that you're on the radar of a doctor and they're just watching you and they're watching the cancer perhaps progress. And if there's a case to treat at a certain point, they will. Yes.

Okay. So we see this rise in late-stage diagnoses of prostate cancer that seem to match up with when the recommendations were made against using the PSA test. Does this study, does it make the connection between these two things? So it makes a temporal sort of hypothesis level connection, right? It looks at the when some of these changes started happening in time and compares it to when we got the U.S. and Canadian recommendations. However, this study does not look at whether the cases that are evaluated here, whether these men had PSA screening. That's just not something that Canada tracks the way it does cancer cases.

All of those numbers are reported out to stat scan. And the authors of this study said they would very much love to have information about how frequently men are screened and whether the cases that were reviewed in this study, whether those men had a PSA test earlier on in the course of their lives. But we just don't know. And so I think it's really important to point out that this is not a test evaluating whether or not the PSA is good for screening. Good point to make. Are there other things that could account for this increase in diagnoses? You know, I did have one of the authors of the original 2014 Canadian guideline against using the PSA suggests to me that we could be finding more stage four cases because we now have more precise and better diagnostic scanning approaches.

So what that would mean is that if perhaps you don't have as good quality a scan, maybe you can't catch, you know, a tiny little bit of cancer that has spread outside the prostate. but that now we can, right? So something that might have been evaluated as stage three before can now be evaluated as stage four. However, the authors of the study said those changes in the imaging quality are fairly recent, more recent than what is reflected in the time period of this study. Okay. So what are the rules about who can get a PSA test in Canada? Do you have to pay for it? Okay. So that's a great question. First of all, I should say that there are no rules around who can. can and should get a PSA test. I say this because so much is really left to the individual discretion of people's doctors. So as we discussed earlier, the most recent sort of formal Canadian guideline we have is that the PSA test should not be used as a screener.

However, there are plenty of doctors on the ground who do see some utility, especially for men who might be considered at higher risk for prostate cancer. And so some doctors do go ahead and order the test and some patients seek it out themselves. Now, because of this lack of like a formal recommendation, the status of whether the test is publicly funded really differs from province to province. So, for example, in Ontario where we are, if you want a PSA test, you have to find a doctor who's willing to order one for you and then you do have to pay out of pocket. Is there a sense that Canada's guidelines around PSA screenings could change? Potentially, yes, for two reasons. One thing I should point out is that we talked about the American recommendations from 2012, and that's when they said, hey, don't use this.

The Americans did slightly change their recommendation in 2018 to say that for men between the age of 55 and 69, they could consider a PSA test through something called shared decision making with their doctor, which is essentially them saying rather than a hard no. if you're in that age ban, you might want to consider talking to your doctor about the harms and risks and maybe consider it. In Canada, our task force, which is called the Canadian Task Force on Preventive Healthcare, they were in the midst of working on an update to their recommendation when the task force work was ground to a halt earlier this year. We'll be right back. So, Kelly, before we went to break, you were mentioning that there's this hold up in changing the guidelines because work has stopped at the Canadian Task Force on Preventive Health Care.

Before we get into what's happened there, what is this task force? And what do they do? This task force is an independent body of experts. They're federally funded. And they provide advice on all kinds of different aspects of preventive health care with an audience in mind of family doctors. So you're your frontline family doctor who has to treat all kinds of patients with all kinds of different illnesses and who really doesn't have the time to go through and evaluate, you know, dozens or perhaps hundreds of studies on each different area of medicine that they're required to look over for their patients. So they rule out guidelines on things like cancer screening, on falls prevention, on prevention of depression, tobacco, like on all kinds of different areas where, you know, if you follow their advice, then hopefully family doctors will be providing good

advice to patients on how to keep themselves from getting sick and stay in good health. Okay, so something's going on here at the task force. What's been going on? There has been a ton of controversy around the work of this task force in the last few years. The main point of contention has been their recommendation for breast cancer screening. Their general recommendation is that once women hit age 50, they should start getting regular mammograms. I should make clear as well that these are recommendations for screening. This is different from if you are a woman who has any kind of symptom of breast cancer, right? So if you found a lump in your breast and you went to your doctor and asked for a mammogram,

that is not considered screening. Screening is for people who don't have any symptoms. Okay. So in 2024, this task force produced a very long-weighted update to its recommendations on mammography for average risk women. And what it says is, said was that women in between the ages of 50 and 74 should get a mammogram every two to three years. But for women in their 40s, and this was kind of the key group that everybody was watching to see how the task force would rule, the task force said we don't recommend sort of proactive systematic screening of women in their 40s. However, if there are women in their 40s who really want a mammogram, they can discuss it with their doctors and hear about the, the risks and the benefits and then decide if they want to go forward. So that may sound like it's a small difference, but in practical terms, it's the difference between if in Ontario, for example, you hit your 50th birthday, you'll get a letter in the mail from the breast cancer screening program, urging you to get a mammogram, telling you where you can go to get one if you don't,

you don't have a doctor who's available to help you navigate that. And then you'll get reminders. You are part of a program. You know, the advice is clear. Go get one. In their 40s, it's more like, it's up to you. There was such pushback to that recommendation, in part because the United States Task Force had the year before lowered its recommended starting age to 40. There was so much pushback against the task force position on breast cancer screening for women in their 40s that ultimately the Federal Minister of Health appointed some external experts to take a look at the governance and processes of this task force as a whole. And then in March of this year, even before that expert panel released its recommendations and released its review,

the health minister said, okay, everybody at the task force, put down your tools, we're pausing your work. Wow, that's so interesting. I find what it's interesting here, too, is that, you know, it sounds like the U.S. decided to go down to 40, but this task force in Canada did not decide to do this. Do we have any sense as to why? So when I was covering the U.S. decision and I spoke with some of the authors of their guideline, what one of them said to me was that they made the decision because they were seeing a clear increase in the rates of breast cancer among women in their 40s.

And so they felt the balance had tipped from the harms outweighing the benefits to their being more of a benefit and less of a risk. Here in Canada, they still felt like the evidence just wasn't clear that the benefits outweighed the harms for women in their 40s. And it is less common for women in their 40s to get breast cancer than older women. Like many cancers, breast cancer is the disease of aging. And it does become more common as women get older. So they in Canada felt that the better route supported by the evidence was to leave it to share a decision making for women in their 40s rather than making a proact. recommendation that all women be screened.

I imagine some of this blowback was happening because it's coming at a time when there is an increase, or at least we're hearing about an increase in cancer diagnoses in younger people. So I'm guessing people might want to have more screening at a younger age. And I can understand why people feel that way. I mean, the idea of discovering a cancer very late in the progress of the disease, when the treatment is much more difficult and the hope of surviving is lower. I can totally understand why people's feeling is that if there's more cancer, certain types of cancer among young people, why not lower the screening age?

Now, for those who disagree with that position, and that includes the task force, you know, which is full of experts on reading the evidence around these screening programs, you know, they point out that there are harms to overdiagnosis and harms to over-treatment and that you cause women, you know, a unfortunate amount of stress and concern when they think that, you know, for example, something was spotted on their mammogram and they have to go back and do perhaps a second mammogram or an ultrasound, that we shouldn't dismiss some of the stress that goes along with those, say, false or inconsistent early findings. And that's really part of the argument for limiting screening to people

who are at high risk of cancer. So if this task force is frozen right now, what exactly does that mean? Well, what it means is that after the external review was released and it made some recommendations about how to govern and run the task force, the health minister has said a new version of the task force should be up and running by next spring. In the meantime, they were working on several different guidelines. One of them that was being revisited was the prostate cancer screening guideline. Another one was for cervical cancer, which is another area where screening policy has changed a fair bit in the last few years, but the task force hasn't updated its guidelines in that area since 2013. Okay. Yeah. Can we talk a little bit about cervical cancer?

because there's still a lot of debate around how when we screen for cancers. But it sounds like maybe cervical cancer is one that's maybe less controversial. Can you tell me about that? Yeah, I think it's safe to say that the cervical cancer screening program is one that's been a huge success and doesn't have a lot of controversy surrounding. In fact, if you've heard anything about cervical cancer screening in the news lately, it would just be about the concerns that we're not reaching all the women who do need to be screened in order to present this cancer.

So your cervical cancer screening is generally for years and years and years has been your pap smear, which most women will be familiar with. Now, there have been some changes in the last couple of years on how we screen for this cancer. And namely, we've seen the rise of something called HPV testing. So the human papillomavirus is the cause of almost all cases of cervical cancer. If you catch this sexually transmitted infection, you can get a persistent infection with, certain strains that are likelyer to cause cancer. So now, if you go in to get what seems sort of to you as a woman as an experience very similar to your pap smear, if you're in Ontario, for example, instead of doing a pap smear, they'll do a molecular test that

determines whether or not you have HPV. And if you don't have HPV, you can wait five years to be screened again. There are also some provinces that are offering take-home versions of the HPV test, which the hope is women who live, say, in like, rural or remote parts of the province or who don't necessarily have access to primary care, that they can use this at-home testing to test for HPV. So there's lots of interesting things happening on the cervical cancer screening front. Unfortunately, what for a long time was a reduction in the number of cases and deaths that we would see from cervical cancer, rather than continuing to go down, that has recently plateaued in a way that has doctors very worried that, like I said,

certain women aren't being reached with the necessary screening. So, yeah, the cervical cancer picture is pretty different from the prostate cancer picture. Yeah, it's really interesting because this is a case where, like you said, that we're not reaching enough women, right? And the situation here when it comes to prostate cancer is, you know, there's a debate about whether or not to give the PSA test. So, I mean, why are some cancer screenings controversial and some not? I'm assuming it has to do with the harm part of this.

It definitely has to do with the harm part of it. It also has to do with the effectiveness of the screening test. You know, cervical cancer screening, one of the things about it that's so amazing is that if you catch cervical cancer early, you know, you can go in and remove those precancerous lesions and you prevent cancer. Canada actually is taking the position that it is going to try to eliminate cervical cancer altogether by 2040. Now, it's not clear we'll actually be able to reach that tart. but it's possible. So, I mean, you just can't beat a mode of screening that also allows you to outright prevent the cancer. When you look at something like the PSA test for prostate cancer, the benefits are just simply not as clear cut. You do run those risks, like I said, of over-diagnosis

and over-treatment that could lead to incontinence and erectile dysfunction for men who have a slow-growing cancer that might never have harmed them or, you know, they die of something else before the prostate cancer really has an opportunity to grow and spread. So the harms are just more clear there. You know, there's also some related harms. Like not every type of prostate cancer can be caught by the PSA test. So there's cases where somebody has a normal PSA level and thinks that they're fine. They don't need to worry about prostate cancer. And it turns out they get prostate cancer. So it's an imperfect test that carries with it serious risks, but proponents of using it more often think it's better than nothing. So Kelly, of course the

goal in medicine is to prevent harm. And some argue that these tests or screens could cause more harm than good in certain situations. But I think many people would feel like the risk of that perceived harm might be the risk they want to take in order to remove a cancer or to say to catch it early. And a screening for them might feel like the right thing to do. So why not give the choice of people instead of deciding for them? So, you know, in some cases we do, you know, like I mentioned, the case of women in their 40s wanting to get a mammogram, right? Like even the task force, despite all the flack it took, has said that they think shared decision making is appropriate for women in their 40s. And many provinces have moved to publicly funding breast cancer screening

for average risk women in their 40s. You know, a thing we haven't really gotten into in this conversation is that Canada does have a public health system. And so we do need to think about what is the right spending of resources, especially on people who are very young and very healthy and have no risk factors for cancer. On the flip side, you know, should we allow people to pay at a lot of, of pocket if they want to have certain screening tests. And, you know, the PSA is one example where you can choose to pay out of pocket if it's not covered in the province where you live. But if you

find an elevated level, then you're engaging the public system, right? Then you need to talk to your doctor about what that elevated level needs. Perhaps you need to be monitored. So it does sort of kickstart a whole bunch of public spending that could be very necessary if it turns out that, you know, you are a person who has prostate cancer, but it may also be all kinds of testing and monitoring and, like I said, potential overdiagnosis and overtreatment of something that were it not for the PSA test, the man himself wouldn't have ever had to worry about and the system wouldn't have ever had to pay for. But I think for individuals, people are willing to accept different levels of risk and they think about risk different ways, especially

when it comes to their health. Kelly, this has been really interesting. Thank you so much for coming on the show. Thanks for having me. That was Kelly Grant, a health reporter with The Globe. That's it for today. I'm Cheryl Sutherland. Alyssa Wheeler joins us as our Brooke Forbes fellow

and is our associate producer. Our producers are Madeline White, Mikhail Stein, and Ali Graham. David Crosby edits the show. Adrian Chung is our senior producer, and Angela Pichenza is our executive editor. Thanks so much for listening, and I'll talk to you tomorrow.